Wednesday, November 26, 2014

Trench Warfare

Trench Warfare

Emergency nursing is a battle, and the enemy is illness and
injury: automobiles, motorcycles, guns, cancer, obesity, suicidality, violence,
heroin, amphetamines, and narcotics. The
enemy never sleeps – and neither do the nurses in the trenches.

Each shift we see unspeakable harms; babies, children, men
and women, preyed upon by our own species, serious injuries incurred by the
technologies of man, and predation by unseen viruses – mutating, hiding,
eating. Our academic training falls far short of the reality of it all. It
dwells in the archaic principles of a bygone age of nursing; an age of divine
care and heroic selflessness - an age before antibiotics, before MRI, before
genome sequencing, before daVinci surgical robotics, cost centers, ICD coding,
case management, and the cats cradle of legal bondage.Academically, we do not produce nurses for
this kind of battle – they are seasoned in the field, in the trenches with the
enemy – and they either fail after only a few years, or become ED veterans,
legends of tenacity, inkwells of black humor.

Your only allies are your comrades. You are part of a crazy
dysfunctional family of misfits, somehow brought together by adventure, a sound
background in herding cats, and the unwavering ability to withstand the abuses
of mental and physical pressure. There is no personal space, and sometimes you
are cheek-to-cheek to complete a task. Through human sickness, you are all
bound together by touch, and smell, and sight. You know your friends by the
scent of their shampoo or the boniness of their elbows. We engage in bizarre
sudden games of Twister, putting our arms and legs all this way and that, often
times holding down flailing screaming nakedness, or cleaning diarrhea from an
anguished soul, their minds murky with Alzheimer’s. We cry over a dead baby,
and then bring a demanding meth addict his pain medicine, apologizing profusely
for the delay, hoping they won’t file a complaint over their slow service. We can
sense the seriousness of a patient’s condition by the eyes of our coworkers -
no words needed - only that look.
These trench warfare nurses are more than just office mates – they are deeply bound
together from being elbow-deep in atrocities.

There is also a sixth sense that develops over time – one
where you see dead people - although they don’t know it yet. It’s an unnerving
feeling, to know the future of certain patients, to see the walking dead - and
its even more unnerving to know that, short of a miracle, you will soon be
pumping their bodies full of semi-toxic drugs, pumping their chests with
battery operated machines, covering their brains with gauze. This sense grows
more powerful with time – and as it grows, you accept it as a grace, for with
it comes the ability to prepare for the worse, to stay a step ahead of the
downward spiral, perhaps even to alter the course of fate.

Experiences are drawn from an endless pool of suffering and
the complex machinery of the human frame that is its host. Terminal injury
aside, your shift in the trench is made up of a relentless flow of strangers -
strangers who want something. Some are legitimate in their request – to repair
their fractured femur, to breathe, to once again speak and move the right side
of their bodies so that they can tell their family how much they love them –
but many are not, and it is this complex set of customers that bring theater to
the Emergency Department.We, the
nurses, are on stage – and we are the primary actors. It’s an art really, to be
able to go from room to room and change your performance to fit the scene, to
get the job done, to be so convincing. This constant play, however, requires a
tremendous amount of emotion, and only with great effort can it be played out
for the entire twelve hours.

Compassion is a finite emotion. You can run out of it – and
once it’s gone, you hope the shift has ended. Strangely enough, it seems to regenerate. Once
your car leaves the parking lot and is pointed toward home, the day starts to
fade. The images, scenarios, little victories and disappointments, things that
no one outside the theater would ever understand – they all just wither as you
drive home to your family, a friend, a dog, or a good glass of wine. By the
next shift, your compassion meter seems to be back within operating range. ER
trench nurses dole out compassion carefully; it is a need-based commodity, and
a very valuable one at that. Once the words fucker
or cunt are directed at you a few
times in as many hours, you know very quickly who gets the compassion, and who
might not. Empathy – we have loads of that, its part of becoming a great actor
on the Emergency stage, to step into the shoes of our patients, to know what
they feel and want, and to change our language and bodies to deal with their
needs. Compassion though – that is precious.

Human interaction is a complex thing - even more so when
you, the nurse, are guided in your speech by the haunting cloud of legal gloom
that hangs over each of your words. Some patients have a known future, a
certain future that you can predict from your thousands of previous
experiences. However, you are compelled to avoid the truth, to keep your thoughts
and knowledge at bay, you skirt the fact that no matter how much money is
consumed by the institution, their loved one is going to die. Instead, you lie
– or, better yet, remain silent. Oh yes, a miracle might be conjured, but
probably not. You remain silent because people don’t want to hear it – that
their weight is the cause of their medical problems, that their smoking caused
their chronic back pain, that their addiction was the reason they pulled their
own eyes out. Truth is clean, but brutal - and we know it could result in an
unsatisfied customer, reduced reimbursement, a chain of migraines for the
managers, and possible termination. The truth could leave you without a job.
It’s frustrating for sure – but these harsh realities will also wither on the
drive home, slowly shaping a shell of invulnerability - every so slowly.

Dealing with these concerns is not taught in school – it
comes from experience, from thousands of mistakes made, and the learned ability
to repair a mistake. It comes from stories told by your comrades in the trench
– both of success and failure. You drink in the wisdom and knowledge of their startling
tales, add them to your own, slowly building an empire of knowledge. Emergency
nursing is both science and art, and from science comes known facts – kidney
functions, ejection fractions, clotting cascades, neural pathways, and ligament
insertions – but from art comes the soul of nursing. The ER is a sweeping
pallet of colors, and with time, you begin to mix the colors together, blending,
learning, discovering, sometimes having to start over, but in the end,
hopefully leaving each shift with numerous finished paintings. None will be
masterpieces – but perhaps one will be worth framing.

Nursing theory, nursing statistics, research, history,
models of care, concepts of nursing, community nursing (collectively known as jumping throughhoops, by some) – these are great course for those yearning for
work as directors and educators, but for those who desire direct patient care
in austere venues, all encompassing hard science and live preceptorship seems
the most logical path. Experience is understood as knowledge gained by repeated trials, and without a series of
supervised trials, experience will be slow to foster, frustrating, overwhelming,
and potentially dangerous. Under real world conditions, we perform tasks over
and over, perfecting each step, understanding the reason for each move, until
the task is performed efficiently, and
with an elegance of purpose. We work closely with each other, double-checking
our work, transferring our knowledge up and down a mental conduit, a hierarchy
of skills and experiences. ER nurses work on common sense, street smarts,
evidence-based science, protocols, and past knowledge – not a modified Roy
model.

No theoretical
lecture will present you with the truth of the battle – that at any moment you
could have your gloved fingers in a struggling vagina, and ten minutes later
you would be eating a slice of pizza; that you will become a master of urine
concentration, that the nauseating need for diarrhea will pass, and that the
three meals a day of peanut butter and graham crackers are all you really need
anyway. Some of your patients will hate you, and tell you so every time you
give them a meal tray. Some of your patients will love you, want to touch your
hair, ask about your family. Everyone you see driving a car will be a potential
murderer, high on crack, to be watched and avoided, the children in your car
more valuable than anything in your life. The constant coughing of aerosolized infection
will drift into your open mouth – and your immune system will strengthen,
becoming impenetrable, like the amour plating of a panzer tank – and you’ll
wish that just once in a while you could
get sick.

The fellowship of
nurses in the Emergency department is a coalition of shared sorrows and
triumphs, of near death experiences and close calls, of comedic interactions,
violent brawls, blood, urine, and vomit. It’s a place of chaos; old men dying
and babies being born, of wailing and sobbing, and of laughter. We crave the ability to produce a lasting
contribution, but are often times tethered by the very profession we live. We
work in the muck, on the front line – feeling quite alone, standing apart from
the greater architecture that is the hospital, nervous, but so alive. Every day
we see the insides of people, splayed open or draining, but always in awe of a
creation that is beyond one’s understanding. Goodness and evil live in curious
harmony within the ED, fighting it out as we try our best to feed the goodness,
starve the evil, and not be taken down in the process.

And yet, every once
in a while, when it’s dark and the beds are strangely empty, the trench nurses
creep outside and lean against the wintery walls of the building, each feeling
the heat from the others shoulders – and silently watch the snow come down - like
swirling stars, trapped within invisible cones under the lights of the parking
lot.

My friends who work at normal jobs always ask me why I stay.
And always, after a pause, I say,“How
could I leave now?”

About Me

I travel as much as I can afford, and afford much less than I desire. The rewards, however, are priceless.Watching sunlight creep across a red desert valley, glitter through an emerald forest, or transform a desolate expanse of ice and snow into a wrinkled lavender blanket is much more than these photographs can provide. They are simply tiny slices of time, a memory; a single moment of the landscape that will never be the same again.